Medical Records Review & Audit Nurse

Medicare Review & Audit Nurse

Performs medical reviews using clinical/medical information provided by physicians/clinicians and established criteria or clinical guidelines. Documents medical necessity decisions using Medicare LCD. Provides review of claims prior to submission and during audit.

• Performs medical claim reviews: responds to audits request, submission of appeal or reconsideration, Determines medical necessity and appropriateness and/or reasonableness and necessity. Documents medical rationale to justify payment and documents missing records that substantiate not medical necessity
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with Medicare guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to team members. Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback. Assists with special projects and specialty duties/responsibilities as assigned by Management.

Required Experience:

• Two years utilization/medical review, or quality assurance

Preferred Work Experience:

• Medicare and Medicaid experience.
• Medicare Part B claims review experience.

Required Skills and Abilities:

• Strong clinical experience to include home health, rehabilitation, and/or broad medical experience.
• Knowledge of specific criteria/protocol sets and the use of the same. Working knowledge of word processing software.
• Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills.
• Demonstrated customer service and organizational skills.
• Demonstrated oral and written communication skills.
• Ability to persuade, negotiate, or influence others.
• Analytical or critical thinking skills
• Ability to handle confidential or sensitive information with discretion.

Preferred Skills and Abilities:

• Knowledge of Medicare and/or regulations/policies/instructions/provisions, DME, and/or system/processing procedures for medical review.

Job Types: Full-time, Part-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Vision insurance

Medical Specialty:

• Home Health

Physical Setting:

• Office

Schedule:

• Monday to Friday

Application Question(s):

• What is your salary requirement?

Experience:

• Medicare Review: 2 years (Preferred)
• Medicare Audits: 2 years (Preferred)
• DME: 2 years (Preferred)

Work Location: One location